Referring Doctors

Why waste the time with faxes and postage letters.
Take advantage of our online referral submission form.
We provide a simple and convenient way for our referral sources to communicate with us. Our online referral form is the most efficient and convenient way to reach us. Please complete the form below and include the relevant information about your patient. You can also upload images such as radiographs or photos if applicable by selecting our “Choose File“ button. Once uploaded, simply push “send“ and your referral form will be on its way. Our servers are secure and your patient’s privacy is our highest priority.

Same Day Teeth Metro Detroit

Doctor's Name (required)

Email (required)

Phone Number

Patient Name (required)

Patient Phone Number

Referral for


Please fill in characters below so we can verify that you are a real person

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